Veeradej Pisprasert, MD PhD

Transcription

1 Immunonutrition: Asian Perspectives Evidence of Immunonutrition in Asia Veeradej Pisprasert, MD PhD Division of Clinical Nutrition Department of Medicine, Khon Kaen University

2 Outline Immunonutrition: Asian Perspectives Evidence immunonutrition in Asia Veeradej Pisprasert, MD PhD Role of immunonutrition in surgical trauma and burn patient Pornprom Muangman, MD Immunonutrition in cancer: case-based scenarios Egapong Sathitkarnmanee, MD

3 Immunonutrient pharmacologically active nutrients that modulate metabolic and inflammatory response enhance immune function (increasing nitrogen balance and protein synthesis) glutamine, arginine, omega-3 fatty acids, nucleotides, antioxidants (e.g. selenium)

4 Recommendations on Immunonutrients ESPEN Guidelines for Cancer patients 2017 use supplementation with N-3 fatty acids or fish oil to stabilize or improve appetite, food intake, lean body mass and body weight in patients with advanced cancer undergoing chemotherapy and at risk of weight loss or malnourished ESPEN Guidelines for Surgical patients 2017 peri-or at least postoperative administration of specific formula enriched with (arginine, omega-3-fatty acids, ribonucleotides) should be given in malnourished patients undergoing major cancer surgery 44 Arends J, et al. Clinical Nutrition 2017;36: Weimann A, et al. Clinical Nutrition 2017;36:

5 McClave S, et al. JPEN 2016;40(2): Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: SCCM and A.S.P.E.N. Consideration for immune-modulating enteral formulations (arginine with other agents, including EPA, DHA, glutamine, and nucleic acid) should be reserved for patients with TBI and perioperative patients in the SICU

6 Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: SCCM and A.S.P.E.N. M1b. We suggest that immune-modulating formulations containing arginine and FO be considered in patients with severe trauma M2b. We suggest the use of either argininecontaining immune-modulating formulations or EPA/DHA supplement with standard enteral formula in patients with TBI O3. We suggest the routine use of an immunemodulating formula (containing both arginine and fish oils) in the SICU for the postoperative patient who requires EN therapy McClave S, et al. JPEN 2016;40(2):

7 Immunonutrition Products Western Product Asian Product Protein (g/1000 kcal) Source of protein Casein, L-arginine Casein, arginine, glutamine CHO (g/1000 kcal) Fat (g/1000 kcal) Source of fat Structured lipid, menhaden oil Corn oil, MCT, fish oil

8 Most of studies and recommendations of immunonutrition are conducted in Western countries (Western product) How about the evidence in Asia which used Asian product?

9 Chuntrasakul C, et al. J Med Assoc Thai 1998;81(5):

10 Metabolic and Immune Effects of Dietary Arginine, Glutamine and Omega-3 Fatty Acids Supplementation in Immunocompromised Patients Patient characteristics Trauma Burn Cancer No. of patients Average age (yr.) Male Female % of ideal body weight Note Ave ISS = 24 Ave % TBSA = 48 Chuntrasakul C, et al. J Med Assoc Thai 1998;81(5):

11 Metabolic and Immune Effects of Dietary Arginine, Glutamine and Omega-3 Fatty Acids Supplementation in Immunocompromised Patients Chuntrasakul C, et al. J Med Assoc Thai 1998;81(5):

12 Metabolic and Immune Effects of Dietary Arginine, Glutamine and Omega-3 Fatty Acids Supplementation in Immunocompromised Patients Change in Immunological markers P-value Day 7 Day 14 Absolute lymphocyte count < 0.01 NS CD4 + count < 0.01 NS CD8 + count < < 0.05 Feeding of immune formula was well tolerated and significant improvement was observed in nutritional and immunologic parameters Complement C3 < < 0.01 IgG < < IgA < < 0.05 CRP < < Chuntrasakul C, et al. J Med Assoc Thai 1998;81(5):

13 Group A Group B Chuntrasakul C, et al. J Med Assoc Thai 2003;86:

14 Comparison of a Immunonutrition Formula Enriched Arginine, Glutamine and Omega-3 Fatty Acid, with a Currently High- Enriched Enteral Nutrition for Trauma Patients Group A Group B Shorten ICU stay and wean-off respirator day may benefit from using the immunonutrient formula Chuntrasakul C, et al. J Med Assoc Thai 2003;86:

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16 Immunonutrition and Cytokine Response in Patients with Head Injury Group A (IMN) Group B (standard formula) Khorana J, et al. J Med Assoc Thai 2009;92(2):

17 Immunonutrition and Cytokine Response in Patients with Head Injury Khorana J, et al. J Med Assoc Thai 2009;92(2):

18 Immunonutrition and Cytokine Response in Patients with Head Injury Short term immunonutrient feeding can reduce cytokine level, so SIRS and CARS might be controlled Khorana J, et al. J Med Assoc Thai 2009;92(2):

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20 Effects of Immunonutrition on Biomarkers in Traumatic Brain Injury Patients in Malaysia: a Prospective Randomised Controlled Trial Group A Group B Rai VRH, et al. BMC Anesthesiol 2017;17(1):81.

21 Effects of Immunonutrition on Biomarkers in Traumatic Brain Injury Patients in Malaysia: a Prospective Randomised Controlled Trial Rai VRH, et al. BMC Anesthesiol 2017;17(1):81.

22 Effects of Immunonutrition on Biomarkers in Traumatic Brain Injury Patients in Malaysia: a Prospective Randomised Controlled Trial Patients in Group A showed significant reduction of IL-6 at day 5 (p < 0.001) with concurrent rise in glutathione levels (p = 0.049) significant increase of total protein level at the end of the study (day 7) Rai VRH, et al. BMC Anesthesiol 2017;17(1):81.

23 Iamsirisaengthong W, et al. J Med Assoc Thai 2017; 100 (Suppl. 2): S121-S125.

24 Prospective Controlled Trial to Compare Immune- Enhancing and Regular Enteral Diets to Reduce Septic Complication in Major Burn Patients ietary protein 25% 17% Iamsirisaengthong W, et al. J Med Assoc Thai 2017; 100 (Suppl. 2): S121-S125.

25 Prospective Controlled Trial to Compare Immune- Enhancing and Regular Enteral Diets to Reduce Septic Complication in Major Burn Patients In major burn patients, immune-enhancing diet demonstrated trend of decreasing in septic complications the significance in maintaining body weight and increasing in albumin and transferrin level Iamsirisaengthong W, et al. J Med Assoc Thai 2017; 100 (Suppl. 2): S121-S125.

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27 Randomized Study of Antiinflammatory and Immune- Modulatory Effects of Enteral Immunonutrition During Concurrent Chemoradiotherapy for Esophageal Cancer 71 locally advanced ESCC patients being treated with CCRT (5-FU and cisplatin) were randomized into 2 groups Group A (IMN) Group B (standard formula) Sunpaweravong S, et al. Nutr Cancer 2014;66(1):1-5.

28 Randomized Study of Antiinflammatory and Immune- Modulatory Effects of Enteral Immunonutrition During Concurrent Chemoradiotherapy for Esophageal Cancer The levels of CRP (P = 0.001) and TNF (P = 0.014) increased more during treatment in the control group than the treatment group Sunpaweravong S, et al. Nutr Cancer 2014;66(1):1-5.

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30 Randomized Study of Nutritional Status and Treatment Toxicities of Oral Arginine, Glutamine, and Omega-3 Fatty Acids During Concurrent Chemoradiotherapy for Head and Neck Cancer Patients Chitapanarux I, et al. Functional Foods in Health and Disease 2016; 6(2):

31 Randomized Study of Nutritional Status and Treatment Toxicities of Oral Arginine, Glutamine, and Omega-3 Fatty Acids During Concurrent Chemoradiotherapy for Head and Neck Cancer Patients Chitapanarux I, et al. Functional Foods in Health and Disease 2016; 6(2):

32 Randomized Study of Nutritional Status and Treatment Toxicities of Oral Arginine, Glutamine, and Omega-3 Fatty Acids During Concurrent Chemoradiotherapy for Head and Neck Cancer Patients Hematologic toxicity severe grade 3-4 hematologic toxicities: group A > B (P=0.035) Complete CRRT treatment patients in group B had complete CCRT > group A (P=0.013) Chitapanarux I, et al. Functional Foods in Health and Disease 2016; 6(2):

33 Randomized Study of Nutritional Status and Treatment Toxicities of Oral Arginine, Glutamine, and Omega-3 Fatty Acids During Concurrent Chemoradiotherapy for Head and Neck Cancer Patients In head and neck cancer, nutritional counseling and immuno-nutrition deterioration of nutrition status hematologic and non-hematologic toxicity of CCRT Chitapanarux I, et al. Functional Foods in Health and Disease 2016; 6(2):

34 Evidence of Immunonutrition in Asia There are some studies of immunonutrition in Asia, when compare with the Western: Difference in product Limited sample size Difference in patient characteristics and treatment? Evidence of immunonutrition in Asia: trauma, burn, cancer Improved nutritional and immunological parameters Tendency of favorable clinical outcomes

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